865 Exploring Recommendations for an Effective Smoking Prevention Program for Indonesian Adolescents

RESEARCH ARTICLE Exploring Recommendations for an Effective Smoking Prevention Program for Indonesian Adolescents
Teuku Tahlil1, 3*, John Coveney1, Richard J Woodman2, Paul R Ward1
Background: The present qualitative study assessed the need, acceptability and appropriateness for implementing effective and culturally appropriate smoking prevention programs for adolescents in schools in Indonesia. Methods: Snowball sampling was used to recruit participants. The study sample comprised a mixture of staff in the education department, junior high school teachers and individuals who had taught junior high school students in Aceh Province, Indonesia. Data were collected through one hour in-depth face to face or telephone interviews and analyzed using a descriptive content analysis procedure. Results: School teachers and policy makers in education firmly supported the implementation of a school-based smoking prevention program in Aceh. An appropriate intervention for smoking prevention program in schools in Aceh should involve both health and Islamic based approaches, and be provided by teachers and external providers. Potential barriers to the program included smoker teachers and parents, time constraints of students and/or teachers, lack of teachers’ ability, increase in students’ load, the availability of tobacco advertising and sales, and lack of tobacco regulation and support from community and related departments. To increase program effectiveness, involvement of and coordination with other relevant parties are needed. Conclusions: The important stakeholders in Indonesian childhood education agreed that school-based smoking prevention program would be appropriate for junior high school students. An appropriate intervention for smoking prevention program for adolescents in schools in Indonesia should be appropriate to participants’ background and involve all relevant parties. Keywords: Smoking - adolescent - smoking prevention in Indonesia Asian Pacific J Cancer Prev, 14 (2), 865-871

Tobacco use is an everyday part of lives for many Indonesians (Hurt, 2012), putting the country as the third biggest tobacco consumers in the world (WHO, 2008). Among adolescents, findings of the 2000 – 2007 Global Youth Tobacco Survey (GYTS) indicates that approximately 11.8% of adolescents in Indonesia currently smoked cigarettes and 3.8% of them used tobacco products other than cigarettes (Centers for Disease Control and Prevention, 2008). Researchers in many jurisdictions have tried to find an effective measure to prevent young people from beginning to smoke and to date, empirical evidence suggest that school-based smoking prevention programs could provide positive effects on adolescents smoking behaviors (Pertusa, 2011; Menrath et al., 2012). It is suggested that school-based smoking prevention programs should be sensitive to participants’ cultural, ethnic, and socio-economic background (Shetgiri, 2011; McKennitt and Currie, 2012). In other words, in the case of Indonesia a thorough understanding of cultural practices, values and traditions of people should be considered in any smoking

prevention education programs for adolescents in schools in Indonesia. Numerous articles have reported the effectiveness of school-based smoking prevention programs. From their systematic reviews and meta-analyses of published articles between 1985 and 2006, Dobbins (2008) report that school-based smoking prevention programs could reduce smoking behaviours, initiation and intentions at least in the short term. Lotrean (2010) suggest that that school-based smoking prevention programs increased adolescents’ negative attitude toward smoking and social self-efficacy, and reduced the students’ smoking behaviours and intention. Other report (Berman, 2011) concludes that the program increased perceived exposure to anti-tobacco education program and provided positive impact on participants’ smoking knowledge, attitude, and behaviours. To our knowledge, there are no studies focusing on the implementation of school-based smoking prevention and cessation programs in Indonesia. Also, it is unknown whether such a program would be acceptable or appropriate for Indonesian adolescents. The present study assessed the need, acceptability and

Discipline of Public Health, 2Discipline of General Practice, School of Medicine, Flinders University, Australia 3Department of Nursing, Faculty of Medicine, Syiah Kuala University, Banda Aceh, Indonesia *For correspondence: Asian Pacific Journal of Cancer Prevention, Vol 14, 2013


Participants informed their interviews schedule to researcher by oral. the study aimed to examine a depth of understanding. 50% had worked as junior school teacher for over 20 years. and only 40% had never used/smoked cigarettes. aged between 26-30 years (66. Instruments Semi-structured interviews were used with the interview guide being constructed in English and then translated into Indonesia language to allow participants to express their ideas comfortably. The dates. Data analysis Data analysis was completed manually using content analysis (Graneheim and Lundman. 2010). Indonesia. phone or e-mail to discuss about the study procedures further. response rates were over 75% of participants (Thomas. Initially. program providers. for “many” response rates were between 50-75% of participants. The ways in which 866 . this potential participant identified others who might be selected for this study. In keeping with the overall aims of qualitative research. Overall. Initial findings were then forwarded to and discussed with other researchers to seek whether the co-researchers agree with the findings and way how those data were analyzed. 2) the type of program providers. Additionally. policy maker from the education department in the Aceh Province. as appropriate. Asian Pacific Journal of Cancer Prevention. times and places for the interviews were arranged by participants based on their convenience. and the Acehnese postgraduate students from universities in the southern part of Australia.7%). A snowball sampling method was used in selecting the study participants (Hanson. education. (2000) recommend beginning any intervention by testing proof of concept so that an appropriate design can be chosen.. the researcher recontacted the participants by oral. the first researcher reviewed the interview transcripts thoroughly and identified the meanings of each response. rather than provide generalizable views that were representation of the study population. telephone. for “some”.Teuku Tahlil et al appropriateness for implementing a culturally appropriate school-based smoking prevention programs in schools in Aceh. Indonesia. by asking the selected participants to invite their friends participating in this study. School-based smoking prevention program for Adolescents in Indonesia The need for the program: In response to the question “to what extent do you agree with the implementation of smoking prevention programs in schools in Aceh”. potential barriers. all participants were asked some questions about their personal background including age.7%). The present study was part of larger research concerning school-based smoking prevention programs to adolescents in Indonesia. response rates were less than 25% of participants. and/or email. Study design This study employed a qualitative design. and strategy to increase program effectiveness. sex and tobacco smoking experiences. many of the participants were male (50%). Data were collected in 2010 through one hour in-depth face to face or telephone interviews. While telephone interviews were conducted with respondents in Indonesia. Potential participants who matched the inclusion criteria above were asked to contact researcher directly if they want to participate in the study. scope and components of the program. Next. for “a fewer”. taught junior school students for one to ten years (66. Next. and had never smoked/used cigarette (66. (4) the potential barriers of program implementation. Some responses were quantified using four categories. Initially. Specifically. and 5) the possible barriers of program implementation. and for “most”. religious roles in the program. 2011). contents of the interview transcripts were classified into nine themes: the need of the program. response rates were between 25-50% of participants. Tsitsani et al.7%). Face to face interviews were carried out in South Australia. six participants were in South Australia and had face to face interviews and ten participants were in Indonesia and had telephone interviews. Once a confirmation for participation had been received. 2013 Results Characteristics of respondents A total of 16 participants were recruited for the study. The meanings were then condensed and developed into subthemes and themes. reasons for the use of religion. to allow participants to comfortably express their ideas. 40% aged between 41-50 years. Of the ten participants involved in telephone interviews. 70% were male. Questions explored the following: 1) the need for smoking prevention program for junior high school students in Aceh. target participants and implementation methods. researcher contacted one of target participants to inform them about the present study. the study aimed to identify: (1) the need from the perspective of teachers and policy makers of smoking prevention programs for junior high schools students in Aceh. 60% had a bachelor degree. The semi-structured interviews were conducted in Indonesian. 2012). Campbell et al. all participants indicated that they agreed with the implementation of school-based smoking prevention programs in schools in their region. Whilst for face to face interviews. Table 1 provides one example of the data analysis procedure. 4) the scope and component of the program. Demographic description of the sample is summarized in Table 2. Inclusion criteria for participants were that they were or had been junior high school teachers in Aceh or working for education department in the province. 2004. (3) the types of program providers of the school-based smoking prevention program and. the frequency occurrence of each category was determined. Materials and Methods Participants Study participants were recruited from a mixture of junior high school teachers.7%). reasons for the program importance. (2) the scope and components of the school based smoking prevention program. Vol 14. held a bachelor’s qualification (66.

3 in their environment.3 including Tobacco smoking Current smokers 1 6.…” (Participant 02).0 Further the participants stressed that the program 25.8%) children.8%) of the respondents perceived that the 06).0 in cigarette…. Category.5 explained to them in details”.2013.7314/APJCP.they are not deeply aware of and don’t understand 31-40 6 37.3 everywhere that expensive. It should be implemented in school because agreed that the use of Islamic components will be worthy students are at high risk for smoking” (Participant 04).5 what is the risk of smoking. “….8 S1/BS 10 62.“This is a very important and good program to prevention programs?” most of participants (93. yeah were: strongly agreed (31.. “at present condition . need to be included into the program because recently there is an Reasons for the program importance: When asked edict about smoking haram in Indonesia issued by MUI about the reasons why they agree with the implementation and Muhammadiyah…. many school age children are actively smoking.5%). Currently there is no smoking prevention education program for children in schools’ (Participant 16).3 acknowledgement that it is not easy for students to say Never use tobacco 8 50. Children are our future leaders” (Participant “Do you think there is any religious role in smoking 06).Table 1.5%) and social and economy Newly diagnosed without treatment Newly diagnosed with treatment Persistence or recurrence Remission 1 30.. prevalence of tobacco smoking were very high among In terms of Islamic components. even worse in my home town…. There was 46.14.3 Work experiences <10 7 43.3and the price is also.. Vol 14.“I strongly agree with a program to prevent children from smoking. Then.0inform students that smoking is dangerous…reducing life expectancy and causing economical burdens to their S2/Masters 3 18. …as far as we are concerned that cigarette contains very dangerous chemical substances and especially for brain..because many children have started smoking since elementary schools and became chronic in junior high schools. “…it is needed..5 I suppose that this assumption should be corrected… Age (years) 26-30 4 25. its scope is wide or necessary (18. Characteristics of the Study Participants (n including those on health. appropriate for students to prevent them from many The role of religion: In response to the question diseases. 38. is appropriate with the rule. “…we Education Diploma 3 18. “….5%) and had warned students about the dangers of smoking (12. the results identified children in Aceh. A few of participants were also concerned that smoking could negatively affect study progress of students (12. (Participant 02). and Islamic effects on students’ health (37. One Example of Theme.2. SubCategory.8 6.Those kind of information need to be 51-60 2 12. One of the participants hoped that this program could strengthen their endeavor to prevent smoking among students.doi.” (Participant 15).0 30. and addiction.20. chemical substances contained 41-50 4 25.5 Smoking is defined as identity and assumed to be mature… Female 6 37.they smoke Characteristics Frequency (f) % cigarettes without knowing what the purposes are… Sex Male 10 62. also not 31.5%)..0no to smoking because the invitation 31. social and economic status.….7 56. 2013 867 None . Some participants viewed tobacco two topics as being required to be included in the program: smoking is addictive (31.2%) and could provide adverse smoking effects from an Islamic perspective.8 Ever used tobacco 7 43.0 54.” (Participant 06).5%).1 parents….0 5 30. for the program effectiveness. I saw elementary schools’ children have been starting to smoke…” (Participant 01).. Scope and components of the program: Participants advised that any specific program for smoking prevention in schools in Aceh should provide students information about smoking and the adverse effects of smoking.7 so if we want to implement this program.4 100.2 to smoke is massive 50.0 smoking prevention program of smoking prevention program in schools in their region. religious rules” (Participant nearly half (43.0 Also….5%).0should develop individual skills of the students >20 5 31. and obviously appropriate and/ 23.865 Exploring Recommendations for an Effective Smoking Prevention Program for Indonesian Adolescents (37. smoking is absolutely ethically inappropriate for junior high school students.7 (years) 11-20 4 25. strongly support (12. Table 2.2%). “We should provide information in detail on how to deal with smoking invitations from the participants expressed their agreements with the friends so that they quit smoking. “….3 general skills and cigarette refusal skills.8%).0 we can get cigarettes very easily 31. and Code of Data Analysis Scope and component of the program Category Sub-categories Codes Information Cigarette smoking Health effects Social economic effects Educational effect Addiction Skill General skill Refusal skill -Concept of smoking -Chemical substances in cigarette -Advantages and disadvantages of cigarette smoking -Health concept -Risks of smoking -Effects of smoking on human body -Effect of smoking on children -Economic impacts of smoking -Effect of smoking on education -Addiction -Self-confidence -Self-esteem -Self-discipline -Extra-curricular activities -Motivation -Cigarette refusal techniques -Culturally appropriate approach to reject smoking DOI:http://dx.0 3 Asian Pacific Journal of Cancer Prevention. = 16) educational effects. or continue to abstain implementation of the program to children in Aceh 25. very important (37.0 from smoking…. This program is 0….

25%) and others (25. economy and etc” (Participant 04).0%) thought that the program would be useful to all junior high school students in grades 7-9. “The most appropriate target participants for this program are students in second year (grade 8). but I think there is some verses in the Qur’an and also hadits…which suggest that smoking is not good for our health. The most frequent types of program providers mentioned by the interviewed participants were teacher (87. all matched with students’ characteristics and background.not too young or old…. Vol 14.0%) or 8 or both (25. and the availability of tobacco in school cafeteria. “…we know that there is no direct mention of banning smoking in the Qur’an and hadits. skill practices (18.involve all relevant parties…from parent in home…. but I am afraid children have already known that smoking in the context of religion is not seems that we also need to employ religious leaders …” (Participant 08). A few participants thought that the program should be run by internal providers only (12. “Since smoking influences health. interactive teaching methods with high of students’ involvement (31.0%) considered that the program should be delivered by school teachers (internal providers) and experts from relevant fields (external providers). The most frequent terms regarding the appropriate teaching methods for smoking prevention programs in schools in Aceh reported by respondents were lectures (62. tobacco advertising. Target audiences and mode of program implementation: In term of target audiences. As regard with the program implementation strategy. Reasons for the use of religion in the smoking prevention program: Further analysis data of this study indicates that the participants use the Islamic edict not to smoke as the main reason why they believe Islamic teaching should be involved in smoking prevention program in school in their region. Types of program providers: As regard program providers. increase students’ load. preparing program resources such as module to providers.7%). “….0%). I think it will be more appropriate if we involve health party in this program…. the participants noted that this strategy should be used cautiously since not every Muslim considers smoking haram (forbidden). there were a few participants (25. 2013 Teuku Tahlil et al it with other courses. Islamic leader (56. how this program could be implemented” (Participant 01). It will be better if the program is administered during school hours. reward and incentives (6.5%) or external providers only (12. “…initially we invite relevant departments including health department to provide training to teachers or we could ask people from health department to administer the program to students directly…. two alternatives were proposed by participants: (1) run the program as an independent course or (2) combined Asian Pacific Journal of Cancer Prevention. “Teachers. If they can not give students good example. providing training to providers.Also school should be free from smoking including smoker teachers and the availability of cigarettes and cigarette advertisements in school canteen” (Participant 15) Discussion Findings of this study suggest that school-based smoking prevention and cessation programs were strongly supported by junior high school teachers and 868 .tobacco industries… and the easy access of cigarettes in the community” (Participant 16). “……We should explain about the meaning of “haram (prohibition)” of smoking to students. many participants (75.” (Participant 14).” (Participant 09). establishing smoke free environment in school. “… I think it might be ineffective if provided after school hours because children have other activities” (Participant 09). smoking parents.8%).5%). A few of them advised that this program should be provided to students in certain grades. and avoiding any burdens to students.0%).5%). “I observed that many teachers are active smokers…So. such as grades 7 (25. school teacher in school…experts in smoking or people who know about smoking such health experts and religious leaders….rules about smoking. followed by health personal/expert (68.” (Participant 15). seminars (12. “We do not need a special course for smoking prevention program. the teachers smoke cigarettes in class rooms… the high proportion of smokers among religious leaders and parents….5%).2%). As religious people. This is an issue….8%) viewed smoker teachers as the main potential barrier to this program. While other told time constraint. Potential barriers of the program: Some participants (43. participants consider children in Aceh would follow the program if Islamic teaching was used. “I think it is very important to involve religion. Strategies to increase program effectiveness: The respondents highlighted several recommendations for the effectiveness of program implementation as follows: involving relevant parties into the program implementation and process. lack of teachers’ ability.2%). Participants also suggested that several external factors such as tobacco and its regulation.. we can say to them that harming our health intentionally is prohibited in our religion” (Participant 13).8%). good presentation techniques (6. We can integrate it into other existing relevant courses in the school such as math.5%).but I suggest we should slightly link to religion where smoking can harm their health. and budget. many respondents (50. running the program gradually and continuously. they are in the middle program…. material to students. what sort of prohibition is that? …and we should also elaborate a number of reasons on how and in what ways smoking is prohibited…(Participant 02).2%). physic.. case studies (18.5%). However. social sciences…. However. followed by using interesting audiovisual aid (37. community and support from health department should be addressed to assure the program can be run successfully.tobacco plantation….0%) who reported that the program can be implemented in schools in Aceh without any problems.

2. As a religious area in which Islamic laws are applied. school-based prevention program should match the needs of participants and be representative of. health. 2012) and behaviours (Wen. (2008) reported approximately 64. and tobacco refusal skills. seminar. and tobacco refusal skills. and educational perspective by the respondents. 2011) The findings of this study suggest that an appropriate strategy for smoking prevention program for adolescents in Aceh should include information about smoking. Further. smoking effects.. There was evidence for a belief that school-based smoking prevention programs could be used as an effective strategy for tobacco control program for children in a variety of ways. tobacco smoking is viewed as identity and a medium to increase their social status. 2011. As the proportion of tobacco smoking among children in their region is high. 2011). Tobacco advertisements. poster and material display. 2012). These notions correspond with previous reports that describe the high tobacco smoking proportion and its associated problems in Indonesia including among children..9%) and newspapers or magazines (82. However. the participants recommended the use of lectures. Also. Indonesian Muslims differ in their view about smoking. et al. the findings indicate that school-based smoking prevention programs should be appropriate to students in grades 7-9 but would be better if it can be started at elementary schools. and sponsorships can be found easily across the country. A recent review of schoolbased smoking prevention programs by Park (2006) show that majority of the programs were delivered through lectures.. Indonesia is home for millions of tobacco users with males reported to have the highest user rates (65%) and far below was females (4%) (Nichter.7314/APJCP. promotions. Tobacco is accessible to Indonesians. Colby et al. 2010). the introduction of smoking prevention program in schools was considered vital by the participants.. Cultural sensitivity is important to increase program effectiveness (Flay. 2008). 2008) at some time or another. Berman et al.. cigarette price and taxes are low in Indonesia. interactive teaching methods. Other studies believed teachers were the most appropriate people to run school-based smoking prevention programs (Dobbins et al.. 2010). 2009). 2009.. Additionally. Indonesia. 2006). Students at all education levels are possible participants of the interventions. self-confident. questions and answers. Warren et al. Berman et al. 2010. 2010). These findings are in line with current development in schoolbased smoking prevention program elsewhere. using Islam in intervention including in tobacco control remains controversial among public health community (Jabbour and Fouad. and (3) social influence model. Tobacco use is a part of culture for many Indonesians. McKennitt and Currie. DOI:http://dx. Park noted that program effects were higher among interactive programs than those in non-interactive ones. when individual undergoing the important stage of their development and before they start tobacco smoking (Sherman and Primack. In general. However.14. Yong.865 Exploring Recommendations for an Effective Smoking Prevention Program for Indonesian Adolescents some perceive smoking haram (forbidden) while other consider makruh (objectionable) (Taylor. Asian Pacific Journal of Cancer Prevention. Smoking was considered inappropriate for school children from moral. successful and effective program components to prevent tobacco use should comprise information about effects of tobacco smoking.. 2010). Almost all of participants in this study agreed that the program could be run by school teachers. 2009). social influence toward tobacco use.. With regard to program participants.. and by video. demonstrations/ by audiovisual aids. 2013 869 .. brain storming and role play. newspaper in education and games (Park. While other used experiments..2013. et al suggests that the involvement of external providers such as health professionals. and counseling as program delivery methods. since adherence to the smoking law is varied among the Acehnese Muslims. For children. 2010).7% of young Indonesians having been exposed to environmental tobacco smoke (ETS) in their dwellings and over 81% reported having exposed to the ETS in different public places. Schoolbased smoking prevention program should be provided to students at an early age.. Lotrean et al. the use of Islamic teaching is believed by some participants to be a method of increasing the effectiveness of the program in children in Aceh. 2010. and friendship (Nawi.. 2009. some respondents argued against this approach. Vol 14. 2004. and sensitive to the participants’ socio-economic and cultural background (Shetgiri. (2) social competence/affective information. 2010. and introduced information communication technology. Further.. According to the CDC (La Torre et al. The prevalence of tobacco smoking is considered unacceptably high among children in Aceh. the vast majority of adolescents in Indonesia reported having viewed cigarette advertisements on billboards (92.. playing a significant role in social and political system in the country (Hurt et al. 2012). maturity. Dobbins. intention to smoke (Lotrean et al.doi. The Jakarta Post. discussion. volunteers. 2009). This study also identified several potential problems for the implementation of school-based smoking prevention programs in Aceh include the high frequency of teacher smokers and the availability of tobacco and tobacco advertisements in or around school building.policy makers in educational setting in Aceh. 2004). empirical evidence suggests that Islam can be an effective strategy for smoking prevention (Jabbour and Fouad. economic. 2011. attitude (Berman et al. Some participants also noted the importance of including external providers such as health professionals and religious leaders as program provider. To be optimally effective. case studies. Tahlil. and researchers appeared to produce positive effects on program (Dobbins et al. School-based smoking prevention program could provide positive effects on students’ smoking knowledge (Wen et al. Wiehe (2005) found three categories of program interventions in their systematic review of school-based smoking prevention trial: (1) information deficit/health 2008). 2010). with elementary schools students considered as the most appropriate age to start the program (La Torre et al. The US Centers for Disease Control and Prevention (CDC) education curricula for tobacco put these components into the curricula (La Torre et al..8%) (Aditama et al. et al. 2007).

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